Diabetes is the most common endocrinological disorder in the US, and racial disparities in outcomes have been widely documented across medical literature. The US Department of Health and Human Services cites that African American adults are 60 percent more likely than non-Hispanic white adults to have been diagnosed with diabetes by a physician. Statistics from the CDC further show that in 2017 African Americans were twice as likely as non-Hispanic whites to die from diabetes . Here we focus on two lesser-known cases of race influencing care in the field of endocrinology.
Osteoporsis Risk SCORE
(Simple Calculated Osteoporosis Risk Estimation)
"Despite bone mineral density (BMD) differences, the gradient of risk for fracture from BMD and other clinical risk factors appears to be similar across ethnic groups. Furthermore, BMD variation is greater within an ethnic population than between ethnic populations."
“Although both [instruments] can reduce the use of DXA scans for screening for osteoporosis, lower sensitivities [using both instruments] resulted in underrecognition of osteoporosis and may limit their clinical usefulness in an ethnically diverse population.”
Cass et al. (2006)
This instrument screens for osteoporosis through measurements including age, race, rheumatoid arthritis, history of nontraumatic fracture over 45 years of age, estrogen use, and weight. It is targeted towards postmenopausal women. Studies have demonstrated a poor specificity . Other tools exist, but these tools also assume a lower risk of osteoporosis in individuals who identify as Black. Together, these may lead to systematic underdiagnosis of osteoporosis for Black patients, while perpetuating centuries old stereotypes of “thicker bones" in Black adults. While a notable systematic review of peer-reviewed literature on bone mineral density (BMD) found potential differences in BMD based on geographical and ethnic groups, it is unclear how each study defined race/ethnicity (i.e. self-report, observer assignment, etc.).
- Cass et al. found that the SCORE instrument missed 70% of Black women with osteoporosis, with a sensitivity of just 30%.
- Although there is an argument that these algorithms can be used to reduce unnecessary screening, does their use make sense if the majority of patients are underdiagnosed?
Fracture Risk Assessment Tool (FRAX)
"The principal findings from this large, population-based study demonstrate that African Americans were substantially less likely to receive prescription osteoporosis medications than Caucasians, even after adjusting for socioeconomic factors and clinical risk factors for fracture."
Curtis et al. (2012)
"For Asian women who have a femoral neck BMD T-score of −2.5 (osteoporosis) and no other risk factors, the 3% FRAX-calculated threshold for hip fracture would not be crossed until the age of 75 years, while this threshold is crossed much earlier (at the age of 67 years) for similar white women."
Lo & Ettinger (2020)
FRAX is a tool used to estimate 10-year risk of major osteoporotic fractures and 10-year risk of hip fractures. It uses factors including age, sex, weight, height, previous fractures, family history, smoking, glucocorticoid use, rheumatoid arthritis, secondary osteoporosis, alcohol, and femoral neck bone mineral density. There are different variations by race, and it is unclear how beneficial these variations are. Current literature suggests that this algorithm may not effectively stratify risk, and therefore have no positive impact on clinical practice. Opponents of FRAX suggest that its continued use supports a belief in practitioners that Black patients are less prone to osteoporosis, further hindering their treatment.
- Even studies that recommend the use of racial variations of FRAX have noted that Black patients are less likely to receive osteoporosis medications.
- Recent publications have drawn into question the accuracy of FRAX in predicting fracture risks for different groups. As such, scores such as FRAX may lead to differential treatment and increased risk of adverse after fractures in minorities, as is widely acknowledged in the literature.